Provider Demographics
NPI:1770595217
Name:BLACK, BRUCE CHARLES (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:CHARLES
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:372 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-6202
Mailing Address - Country:US
Mailing Address - Phone:781-239-3550
Mailing Address - Fax:781-239-3272
Practice Address - Street 1:372 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6202
Practice Address - Country:US
Practice Address - Phone:781-239-3550
Practice Address - Fax:781-239-3272
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA537932084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ04142OtherBLUE CROSS OF MA
MA053793OtherTUFTS HEALTH PLAN
MAB97786Medicare UPIN
MA053793OtherTUFTS HEALTH PLAN